Palliative Care



Palliative Care


Lauren Cobb

Teresa P. Díaz-Montes





ETHICAL CONSIDERATIONS


Do Not Resuscitate/Do Not Intubate



  • Do not resuscitate/do not intubate (DNR/DNI) is often a difficult discussion that patients expect their doctors to initiate. In general, the conversation should address the goals of treatment and the patient’s priorities, including prolongation of life and quality of life, preferences for life-sustaining therapies, and goals for pain management.


  • A patient can decide to be DNR/DNI but still pursue aggressive treatment; likewise, a patient can decide to pursue palliative treatment and still desire full resuscitation.


  • Data show that resuscitation and intubation efforts in oncology patients are rarely successful.


  • DNR/DNI discussion is urgently indicated if



    • death is imminent or the patient is otherwise at high risk for intubation or resuscitation (e.g., compromised pulmonary function);


    • the patient expresses a desire to die;


    • the patient or her family wants to discuss hospice options;


    • the patient has been recently hospitalized for progressing illness; or


    • the patient has significant suffering coupled with a poor prognosis.


Legal Considerations



  • The patient’s decision may not always be the same as that of her physician or family.


  • The principle of autonomy is an important consideration in American medicine.



    • Living wills and DNR orders can ensure that patients’ wishes are carried out.


    • Situations in which patients’ surrogate decision makers may disagree with previously formulated advance directives are common.



      • Legally and ethically, a surrogate decision maker must clearly follow the advance directive formulated by a competent patient.


  • Patients have the right to refuse or to withdraw care.


  • Permitting death by not intervening is distinct from the action of killing.


  • Physician-assisted suicide (i.e., a doctor provides a patient with the means to commit suicide with knowledge of the patient’s intent) is legal only in Oregon and Washington states.


  • Voluntary euthanasia (i.e., an intervention to end a patient’s life with her consent) is illegal in all states.


  • Difficulties can arise when patients and their families request treatments considered futile or inappropriate by their physicians.



    • No legal or societal consensus exists for situations in which patients and families disagree with physicians’ recommendations to stop treatment.



    • Consultation with an ethics committee or palliative care can be helpful.


    • Excellent communication regarding educational, spiritual, and psychosocial needs can often resolve these conflicts.


END-OF-LIFE CARE: PAIN MANAGEMENT



  • One of the most common and frightening symptoms for patients with terminal illness


  • Patient surveys have shown that pain associated with advanced illness is often undertreated and that approximately 40% of cancer pain is undertreated.


  • Pain should be addressed aggressively with multimodal therapy.



    • The World Health Organization (WHO) pain ladder provides guidelines for pain control escalation (Fig. 51-1).


    • Adjuvants include medicines, interventions, and alternative/complementary approaches designed to reduce fear or relieve anxiety.


    • Pain can be visceral, somatic, or neuropathic; many patients have multifactorial pain.






Figure 51-1. The WHO three-tier analgesia ladder depicts a rationale for escalating combination pain treatments as necessary to achieve pain control goals. Pain medications should be administered in order (nonopioids, then mild opioids like codeine, then strong opioids like morphine) until pain relief is achieved. Analgesics should be scheduled rather than given as needed. (Adapted from World Health Organization. Cancer pain relief and palliative care: report of a WHO expert committee. Geneva, Switzerland: World Health Organization, 1990:7-21.)


Medical Treatments


Nonsteroidal Anti-Inflammatory Drugs



  • First step in the WHO pain treatment ladder


  • Can act synergistically with opioids



  • Should be given around the clock if pain is constant—twice daily options can aid in compliance


  • No nonsteroidal anti-inflammatory drug (NSAID) has greater efficacy than another.


  • Side effects include platelet inhibition (some nonsteroidals, such as Trilisate, do not inhibit platelets), gastrointestinal (GI) effects, and nephrotoxicity. These can be especially pronounced in older, frail patients.


  • Often contraindicated in clinical trials or while receiving chemotherapy. GI prophylaxis is usually indicated for long-term palliative use.


  • Acetaminophen is often just as effective and may be safer in some situations.


Opiates



  • Second and third steps in the WHO ladder


  • Opioids can be considered first line for terminal patients, especially those with severe pain.


  • When pain is constant, escalate to around-the-clock dosing or longer acting narcotics with rescue doses as needed.


  • There are various formulations and routes of administration (there is variation in response to these formulations and none are universally preferred over the other):



    • Mu opioid receptors are a subset of opioid receptors that provide anesthesia in response to specific narcotics. Pure mu agonists specifically target these receptors for pain relief: morphine, fentanyl, oxycodone, hydromorphone, and methadone.



      • Morphine: Available in oral tablets, solutions, elixirs, suppositories, and injectable formulas. Also available sublingually but is poorly absorbed in that route. Metabolized by the liver and excreted renally. Administer cautiously with renal insufficiency.


      • Fentanyl: Available in transdermal, transmucosal, and injectable formulations. No active metabolites, which make it useful in renal insufficiency. Relatively lower propensity to cause histamine release and itching.


      • Hydromorphone: Available in injectable and oral formulations and has a short half-life. Also useful in renal insufficiency, as its active metabolite is present in low concentration.


      • Oxycodone: In formulations alone or mixed with acetaminophen. Available in immediate- or extended-release formulas.


      • Methadone: Mu agonist but also N-methyl-D-aspartate antagonist which helps to reverse opioid tolerance. Long half-life. Risk of prolonging QT interval.


      • Meperidine (Demerol) should be avoided, especially in renal failure, because its metabolite can accumulate and cause seizures.


      • Partial agonist/antagonists (nalbuphine or buprenorphine) should be avoided because they can precipitate withdrawal.


      • Refer to dosing guidelines (Table 51-1), as intravenous (IV) opioids are three times more potent than oral doses. Hydromorphone and fentanyl are much more potent than other opiates.


Severe Pain Crisis



  • Treat with a rapid taper of a fast-acting IV narcotic or with IV patient-controlled analgesia (PCA).


  • Once acute pain is controlled, calculate the dose and convert to a long-acting form.


Side Effects



  • To alleviate side effects, decrease the dose, change to a different narcotic, change the route, or treat the symptoms.



  • See the following text for treatment of nausea and vomiting.


  • Constipation is frequently a problem for patients on around-the-clock opioid. A bowel regimen should be prescribed; senna is often the first choice.


  • Sedation is common, although tolerance often develops.


  • Treat pruritus with Benadryl or low-dose nalbuphine or naloxone.








TABLE 51-1 Opioid Analgesics: Equivalent Dosing for Various Narcotic Formulations

































































Analgesic


Parenteral IM/IV Dose (mg)


Oral Dose (mg)


Half-lifea (hr)


Peak Effecta (hr)


Morphine


10


30


2-3


0.5-1


Hydromorphone


1.5


7.5


2-3


0.5-1


Meperidine


75


300


2-3


0.5-1


Fentanyl


0.1


Variable


3-12


0.1-0.25


Levorphanol


2


4


12-15


0.5-1


Oxycodone


NA


20


2-3


1


Codeine


130


200


2-3


1.5-2


Hydrocodone


NA


30


4-6


0.5-1


Methadone


10


20


12-190


0.5-1.5


Use rows to convert dosing route and columns to convert between medications.


a Parenteral dosing except for oral-only medications.


IM, intramuscularly; IV, intravenous; NA, not available (oral only).


Adapted from Barakat RR, Markman M, Randall ME. Principles and Practice of Gynecologic Oncology. Philadelphia, PA: Lippincott Williams & Wilkins, 2009:993.

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Oct 7, 2016 | Posted by in GYNECOLOGY | Comments Off on Palliative Care

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